The use of patient‐reported outcome measures by healthcare professionals in specialized asthma management centers in French‐speaking Belgium: A mixed‐methods study

Abstract Introduction Recently, the literature has promoted the use of patient‐reported outcome measures (PROMs) in clinical practice as a means to foster patient engagement. However, conditions necessary to support the use of PROMs to encourage asthma patient engagement are not clearly defined. Therefore, we sought (1) to explore the current and ideal use of PROMs by healthcare professionals (HP) in specialized asthma management centers in French‐speaking Belgium and (2) to understand under which conditions the use of PROMs contributes to patient engagement. Methods We undertook a mixed‐methods study with both anonymous online survey and in‐person qualitative semi‐structured interviews conducted with HPs to understand their perspectives on the routine use of PROMs. HPs were recruited from 16 asthma centers (French‐speaking Belgium) identified via the Belgian Respiratory Society. Results Of the 170 HPs identified from the 16 participating centers, 51 (30%) responded to the survey (n = 51) and 11 completed semi‐structured interviews. 53% (27/51) of the surveyed HPs reported using PROMs primarily for asthma monitoring and clinical research while all reported that PROMs should primarily be used in practice to facilitate communication with the patient and to address neglected aspects of the care relationship such as the psychosocial aspects of the disease. The qualitative interviews revealed avenues for moving from a medical‐centered and utilitarian use of PROMs to a use serving patient engagement. This would require HPs to go beyond their current representation of PROMs, to use instruments offering a more holistic image of the patient, to incorporate PROMs into a digital tool and to integrate PROMs in a patient education process. Conclusion The main findings of this study suggest relevant avenues for using PROMs in ways that support patient engagement.


| INTRODUCTION
Asthma is an important public health problem affecting approximately 334 million people worldwide 1

and 43 million people in
Europe. 2 In addition to its high prevalence, asthma is also responsible for major direct (e.g., hospital admission and the cost of pharmaceutical medicines) and indirect (e.g., school and work days lost because of exacerbations) economic costs 3,4 and has a negative impact on asthma patients' quality of life. 5,6 To deal with the public health implications of asthma, several studies consider patientcentered care as a lever to contribute to the improvement of patients' health and the quality and safety of care. [7][8][9] At the beginning of this century, the Institute of Medicine (Washington D.C., USA) recognized patient-centered care as a key goal for improving health care systems 9 and provides a definition according to which the patient-centered care is "a care that respects and responds to the individual patient's preferences, needs and values and ensures that clinical decision incorporates patients' values". 10 Various initiatives-such as shared-decision making, 11 therapeutic patient education, 12 and self-management 13 -are part of this perspective of patient-centered care. Next to these initiatives, the scientific literature has recently recognized the inclusion of patient-reported outcome measures (PROMs) in clinical settings as a way to encourage patient-centered care. [14][15][16] A PROM is an instrument (e.g., questionnaire) that includes any outcome evaluated directly by the patient himself or herself and is based on patient's perception of his/her health status, disease, symptoms, health-related quality of life (HRQL), and treatment(s). 17 Although they also capture the patient's perspective, patient-reported experience measures (PREMs) are different from PROMs. 14,15 Unlike PROMs, which assess how patients experience their illness and its impact on their lives, PREMs assess how patients experience their care process (e.g., satisfaction with information given by doctors or nurses). 14,15 PROMs were originally developed for use in clinical research, as secondary endpoints in clinical trials, to assess the efficacy and costeffectiveness of care of the treatment. 18,19 Over the last decade, PROMs have taken a new role by being increasingly collected and used in clinical practice [19][20][21] to improve the detection of patient problems, to monitor changes in patient outcomes over time, to support clinical decision-making, and to engage patients in their care. [22][23][24] Although the routine use of PROMs has gained importance in Anglo-Saxon countries following the implementation of national programs 14 (e.g., PROMs program launched in England in 2009), nothing similar is currently planned in Belgium. The lack of interest in PROMs in the field of asthma in Belgium raises questions even more so that international guidelines (e.g., GINA) recommend their routine use for asthma management. 25,26 Moreover, PROMs can constitute a simple and effective means of identifying patient preferences, a prerequisite for patient engagement in their care. 24,27 However, the conditions necessary to support the use of PROMs to encourage asthma patients' engagement in their care are not clearly defined in the literature, and further studies exploring the use of PROMs by healthcare professionals (HP) are essential to help researchers and policy makers gain understanding of how these tools impact clinical decision-making. 28 Therefore, in this study, we sought (1) to explore the current and ideal use of PROMs by HPs in specialized asthma management centers (secondary care) in French-speaking Belgium and (2) to understand under which conditions the use of PROMs in the asthma patient-HPs relationship contributes to improve patient engagement in their care.

| Study design
We conducted a mixed-methods study with a sequential explanatory design. 29 In this study design, the quantitative data are further explored with the qualitative data. For the quantitative study, an optional and anonymous online survey was sent to HPs from all centers specialized in asthma management in French-speaking Belgium (n = 19). These centers were identified via the severe asthma registry of the Belgian Respiratory Society (BeRS). For the qualitative study, the survey data were used to construct an interview guide. The latter was used to conduct semi-structured interviews with HPs who agreed to participate in this part of the study.
These interviews were conducted to gain an in-depth understanding of HPs' perspectives. This study was approved by the Liege University Hospital Ethics Committee (Protocol number: 2021/106).

| Participants and data collection
The target population was any HPs (pneumologist, nurse, physiotherapist, psychologist, or social worker) caring for adult asthma patients and working in a specialized asthma management center identified through the severe asthma registry of the Belgian Respiratory Society. The registry includes 19 specialized asthma management centers in French-speaking Belgium. Each center was integrated in a type of hospital structure, divided as follows: university hospital (n = 3), hospital with a university character (these are general hospitals that have been assigned a minority of beds managed by university authorities, without missions of teaching and research) (n = 5) and classic general hospital (n = 11).
Participants were recruited in two main steps. First, the principal investigator of the current study (GL) sent an email to all identified center heads asking if they would agree to participate in the self-administered survey (a questionnaire) made available through an online platform. Second, center heads who responded positively disseminated the online survey link to all their HPs involved in asthma care. The survey invitation stated that it was optional and that results would be anonymous. To collect as many data as possible, the principal investigator sent reminder emails on In addition to collecting socio-demographic data the survey was composed of three main parts constructed from relevant scientific literature. 15,27,30,31 The first one explored the vision that HPs have of patient-centered care through 7 questions scored on a 10-points Likert scale (1 means not at all agree, while 10 means strongly agree). It assessed, on the one hand, HPs' attitudes about the care relationship, and on the other hand, the care relationship as it is really in the practice of HPs. The first part of the survey was accessible to all participants whether or not they use PROMs routinely. The second and third parts of the survey explored the current and ideal use of a medium (PROMs) in the HPs-patient relationship. 15,23,24 In the second part, HPs were asked to answer multiple-choice questions. Apart from the first question asking whether or not participants used PROMs routinely, all other questions in the second part were restricted to participants using PROMs routinely. The third part of the questionnaire was available for all participants and explored HPs' preferences for the routine use of PROMs through multiple-choice questions. were analyzed using Chi 2 tests. All statistical analyses were performed using GraphPad Prism software (version 9.4.1) at a significance level of 0.05.

| Participants and data collection
All center heads who accepted to participate in the survey were contacted again to see if they would be willing to participate in the qualitative component of the study. The center heads who agreed to this part of the study provided the principal investigator with the email addresses of the HPs from their center. From this, a purposive sampling was carried out to obtain a diversity of profiles of the interviewees. To reach this diversity in the participant selection, special attention was paid to the following criteria: professional function within the center (pneumologist, nurse, physiotherapist, psychologist, or social worker), gender, professional seniority and the type of hospital structure in which the center is localized (university hospital, hospital with a university character, and classic general hospital).
Face to face semi-structured interviews were conducted between January 2022 and July 2022. Verbal consent was obtained prior to the interviews. All the interviews were conducted by the principal investigator (GL) who had followed qualitative approach lessons during his training (Master in Sociology). All the interviews were audio-recorded and transcribed into verbatim. No more new interview was conducted when data saturation was reached and confirmed through deliberation by a qualitative team (GL, BP, BV, and DK). This was achieved after 11 interviews. The interview guide (see online Supporting Information S1) was constructed based on results from the online survey, relevant scientific literature 15,27,30,31 and the three interacting poles (current situation, expected situation, and prospects for action) according to the "need analysis model" developed by E. Bourgeois. 32

| Data analysis
A thematic analysis was carried out on all anonymized 11 HPs' narratives. 33,34 From the participants' narratives, the principal investigator (GL) extracted quotations to compile them into contentsimilar groups called "codes". Then, the codes were grouped into broader groups called "themes". Following an iterative process, the introduction of a new code involved the rereading of all the narratives to ensure that the data extraction was complete. All this work contributed to the construction of a first analysis grid (e.g., list of themes). Next, three other investigators and experts in qualitative  in the study and were distributed as follows: classic general hospitals (9 centers), hospitals with a university character (4 centers), and university hospitals (3 centers). Of the 170 HPs from the 16 participating centers, 51 responded to the survey (n = 51) leading to a response rate of 30%. Most of the respondents were women (59%) and pulmonologists (59%) working in a care center integrated in a university hospital (53%) and localized in the Walloon Region (73%) ( Table 1). 3.1.2 | Healthcare professionals' vision of patientcentered care (n = 51) For each of the 7 questions assessing the HPs' vision of patientcentered care, there was a statistically significant difference between the attitudes and the practices ( Table 2). Between question one exploring "the time spent giving simple, clear, and complete information to the patient about health problems", and the final questions exploring, "discussion with the patient of the ways to enable him/her to be more autonomous", there was an increasing augmentation in the gap between attitudes and practices showing that HPs' attitudes were more supportive of patient-centered care than their practices ( Table 2).

| The current use of PROMs in routine by healthcare professionals (n = 27)
A slight majority of participants (n = 27, 53%) reported a routine use of PROMs (Table S1). There were significant differences in whether or not PROMs were used routinely based on socio-demographic characteristics. The proportion of participants using PROMs routinely differed significantly by occupational status (Chi 2 test, p = 0.0035) and was higher among respiratory physicians than nonphysician health workers ( Figure S1). Moreover, the proportion of participants using PROMs routinely differed significantly by hospital structure (Chi 2 test, p = 0.0236) and was higher in university hospital and hospital with a university character than in general classic hospital ( Figure S1). The proportion of participants using PROMs routinely differed significantly by gender (Chi 2 test, p = 0.0054) and was higher among men than women ( Figure S1). There was no statistically significant influence of HPs seniority on the use of PROMs (Mann-Whitney test, p = 0.14) ( Figure S1). Of the 53% respondents usually using PROMs (n = 27), 75% and 52% declared they had T A B L E 1 Socio-demographic characteristics of participants (n = 51).

It is my role to do this (attitude) mean (SD)
In knowledge of PROMs through international guidelines and scientific articles respectively (Table S1). The top 3 reasons why they currently use PROMs routinely were to monitor asthma and its progression (81%), to do clinical research (63%), and to allow patients to share their experiences related to their disease (52%) (Table S1).
Regarding the type of PROMs used, an overwhelming majority of participants (88%) responded that they use asthma-specific PROMs.
The other participants declared using generic PROMs or even both types of PROMs (Table S1). The majority of participants declared that PROMs were completed during a face-to face consultation (52%) through paper questionnaires (77%) and that data from PROMs were analyzed only by pulmonologists (88%) ( Table S1). The top three reasons given by the 47% of respondents not using PROMs (n = 24) were the insufficient knowledge of PROMs among health professionals, the time constraints and the lack of financial resources (Table S1).

| The ideal use of PROMs in routine by healthcare professionals (n = 51)
Training on the use of PROMs (80%), more time (65%) and more resources (57%) were the top 3 suggestions given by all the respondents to improve the routine use of PROMs (  (Table S2). The comparison between the reasons for the current use and ideal use of PROMs in routine is presented in

| Qualitative interviews
We conducted 11 semi-structured interviews with HPs having different profiles and working in different types of hospitals (Table 3).

F I G U R E 1
Reasons for routine use of PROMs, comparison between current use and ideal use. PROMs, patient-reported outcome measures. * Significant at p < 0.05 level; ** significant at p < 0.01 level.
LOUIS ET AL.
-5 of 12 The interview time ranged between 37 and 75 min. The transcribed interviews were coded and organized into two main sections, each subdivided into (sub)themes ( Figure 2).

| From a medico-centric and utilitarian use of PROMs
The current operating mechanisms of PROMs � Quantifying patient's experience gives it legitimacy The interviewees explained that using asthma-specific PROMs is a way to introduce the patient's perspective reliably and validly into the care relationship, thanks to the close proximity between respiratory function parameters and asthma-specific PROM data.
I find that the asthma control test (ACT) and the asthma control questionnaire (ACQ) are very good.
They allow monitoring of patients because it is really linked to the symptoms they describe in their daily life.
In general, when these PROMs show significant disturbance, it hints towards an instability of asthma.
Moreover, we often see a correlation between the lung function tests and results of questionnaire.
(pulmonologist 1, university hospital) � The objectification of the patient as a criterion for treatment reimbursement Asthma-specific PROMs are tools that freeze the patient's perspective into "something" that is recognized as necessary for reimbursement of biological treatments. Reimbursement for biotherapy treatments is conditional on the collection of these "things" capturing the patient's perspective.
So to get the agreements, the patients have to be seen after 4-6 months and have check-up. There was a time where PROMs was needed to have reimbursement of a biologic. So it was imposed by the policy. If they want to be reimbursed for their products, the patients must come to the clinic because they must prove that they still need them. So, in that context, they must complete the ACT, the ACQ and the asthma quality of life questionnaire (AQLQ). We are also kind of in those systems where they have to come in to get their reimbursement for their treatment.

Asthma-specific PROMs are part of a predefined division of labor
The use of asthma-specific PROMs does not disrupt the predefined division of labor dominated by the medical profession. The nonphysician health worker role is to accompany the patient in filling out the questionnaires, while the physician's role is to analyze and interpret the results of the PROMs.
I think that we are really there to guide the patient, so that the questionnaires are filled out in the best possible way, because we can have completely different results depending on how the patient responds, so I think that the nurse is there to guide him.
The one who will decide must remain the doctor.
(nurse 2, hospital with a university character).

T A B L E 3
Socio-demographic characteristics of participants (n = 11).

Going beyond the current representation of the use of PROMs
Interviewees recognized the value of an alternative use of PROMs that goes beyond the medical-centric and utilitarian use of PROMs.  (Chief pulmonologist 1, university hospital) If at the AQLQ activity level it's having more trouble, we could redirect to the respiratory physiotherapist, for example. I think that can play that role, but unfortunately, they don't play that role right now, not here at least. But in ideal use, that would be ideal yeah (laughs).

PROMs data as an opportunity and a gateway for patient education
Using other tools, such as generic PROMs, can contribute to patient autonomy but are not sufficient to achieve it. The interviewees voiced that something else is needed to make the patient autonomous and engaged in his care. In this regard, using PROM data can be an opportunity to develop asthma patient education.
But among the ones we use that are specific to asthma, I don't really see how they can contribute to patient autonomy. We also use the hospital anxiety and depression scale (HAD) and you see that is This medico-centric and utilitarian use of PROMs is understood, in the participants' discourse, by the place that asthma-specific PROMs occupy in the current HPs-patient relationship. Rather than being seen as a tool to activate a dialogue, it represents an object that quantifies the patient's experience, helping to make the LOUIS ET AL.  50 This idea is also supported in a study conducted by Santana and Feeny,40 where the authors developed a conceptual framework describing the potential effect of using PROMs in routine clinical care of chronically ill patients. Among the different components composing the model, one concerns the potential of PROMs to enhance patient engagement. According to the authors, this can occur in situations in which clinicians use the PROM data to discuss and educate patients. 40 Our results feed the model by demonstrating, in the context of asthma, that the inclusion of PROMs in an educational approach would require, in particular, the use of tools allowing the capture of a more global image of the patient, as well as an overcoming of the representation that HPs have of PROMs reducing them to a simple number masking the complexity of the context of the patients' lives.
Furthermore, in a country like Belgium where patient education is not formalized and institutionalized, 51 we believe that PROMs can represent a simple and effective trigger to initiate a form of patient education which is recognized as essential in asthma management by international guidelines. 25

| Strengths and limitations of the study
One strength of the study is the fact that it is the first one to explore the use of PROMs by HPs in specialized asthma management centers in French-speaking Belgium. Another strength is the fact that this study used a mixed-methods design which allowed us to understand more deeply the results of the survey. However, the study has several limitations. One limitation is the fact that the survey response rate (30%) might be seen as low. However, it is in line with response rates that can be found in other HP surveys in Belgium. 52 The period at which the survey was conducted corresponded to a low COVID-19 activity in Belgium so that we do not believe that the pandemic has had a strong impact on the response rate. Another limitation is the fact that we did not survey and interview asthma